Effects of tramadol on emergence agitation after general anesthesia for nasal surgery

Abstract

Emergence agitation (EA) is common after nasal surgery. Strong opioids and N-methyl-d-aspartate (NMDA) receptor antagonists prevent EA. Tramadol also acts as an opioid receptor agonist and an NMDA receptor antagonist, but few studies have evaluated the effects of tramadol on EA. This retrospective study investigated whether tramadol is effective for reducing EA in adult patients undergoing nasal surgery.Of 210 adult patients undergoing a nasal surgical procedure under general anesthesia, the medical records of 113 were analyzed retrospectively. The patients were divided into 2 groups: patients who received tramadol during the operation (tramadol group, n = 52) and patients who did not (control group, n = 61). The incidence of EA, recovery time, changes in hemodynamic parameters, postoperative pain scores, and adverse events were compared between the 2 groups.The incidence of EA was higher in the control group than in the tramadol group (50.8% [31/61] vs 26.9% [14/52]; odds ratio 2.805; 95% confidence interval, 1.3 to 6.2; P = .010). Changes in systolic blood pressure in the 2 groups were similar, whereas changes in heart rate during emergence differed depending on the group (P = .020), although pairwise comparisons did not reveal any differences between the groups. Recovery time, postoperative pain scores, and adverse events were similar in the 2 groups.In adult patients undergoing nasal surgery, tramadol infusion decreases the incidence of EA after sevoflurane anesthesia without delaying recovery or increasing the number of adverse events.

Emergence agitation: current knowledge and unresolved questions

“…Among these, although the RSAS and RASS have been commonly used and show high interrater reliability in adult intensive care unit patients [81,82], none of the scales have been validated in the operating room and/or the PACU. There have been few studies of EA in intensive care unit patients [37]; the majority of EA studies have been performed in PACUs or operating rooms [19,20,83].…”

“…The precise pathophysiological mechanism of EA after general anesthesia is unknown [ 19 , 20 ]. In children, proposed causes of EA include high levels of anxiety regarding surgery, new environments, separation from parents, and encounters with unfamiliar medical staff [ 9 , 26 ].…”

“…Although the RSAS and RASS have been commonly used, and show high interrater reliability in adult intensive care unit patients [ 80 , 81 ], none of the scales have been validated in the operating room and/or the PACU. There have been few studies of EA in intensive care unit patients [ 37 ]; the majority of EA studies have been performed in PACUs or operating rooms [ 19 , 20 , 82 ]. Consequently, the reported incidence of EA differed with the evaluation site (e.g., operating room vs. PACU), assessment tool (e.g., RSAS vs. RASS), and definition of EA (e.g., RASS ≥ +1 vs. ≥ +2 vs. ≥ +3).…”

“…Tramadol is an atypical centrally acting opioid that inhibits M1 and M3 muscarinic acetylcholine and nicotinic acetylcholine as well as NMDA receptors [ 106 – 108 ]. In a retrospective cohort study, a single dose (2 mg/kg) of tramadol administered intravenously at the start of surgery was found to reduce the incidence of EA after sevoflurane anesthesia in adult patients undergoing nasal surgery [ 19 ]. The authors speculated that the analgesic, antitussive, and anti-shivering effects of tramadol, as well as its ability to reduce voiding urgency, may have resulted in the prevention of EA.…”

“…ED is not fully equivalent to EA; ED can involve hypoactive signs or mixed forms, as well as hyperactive signs similar to agitation [13 -15]. Nevertheless, in general, the terms EA and ED have been used interchangeably in many studies [16,17]; moreover, the same assessment tools (e.g., Riker Sedation-Agitation Scale or Richmond Agitation-Sedation Scale) have been used for both conditions [18][19][20][21]. However, both EA and ED should be differentiated from postoperative delirium; postoperative delirium is a concept that includes ED (i.e., ED represents the very early onset of postoperative delirium in the operating room or on arrival at the postanesthesia care unit [PACU] immediately after the anesthesia period) [18,21,22].…”